2
The Evolving Role of Hospital-Based Emergency Care

The emergence of the modern emergency department (ED) is a surprisingly recent development. Prior to the 1960s, emergency rooms were often poorly equipped, understaffed, unsupervised, and largely ignored. In many hospitals, the emergency room was a single room staffed by nurses and physicians with little or no training in the treatment of injuries. It was also common to use foreign medical school graduates in this capacity (Rosen, 1995). In teaching hospitals, the emergency areas were staffed by junior house officers, and faculty supervision was limited (Rosen, 1995). One young medical student in the 1950s described emergency rooms as “dismal places, staffed by doctors who could not keep a job—alcoholics and drifters” (University of Michigan, 2003, p. 50).

Over four decades, the hospital ED has been transformed into a highly effective setting for urgent and lifesaving care, as well as a core provider of ambulatory care in many communities. An extraordinary range of capabilities converge in the ED—highly trained emergency providers, the latest imaging and therapeutic technologies, and on-call specialists in almost every field—all available 24 hours a day, 7 days a week.

The appeal of the modern ED is undeniable—it is in some ways all things to all people. To the uninsured, it is a refuge. To the community physician, it is a valuable practice asset. To the patient, it is convenient, one-stop shopping. To the hospital itself, it is an escape valve for strained inpatient capacity. The demands being placed on emergency care, however, are overwhelming the system, and the result is a growing national crisis. The decrement in emergency care capacity and quality, however, is almost invisible to those outside the system. Few people have regular contact with

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Hospital-Based Emergency Care: At the Breaking Point.
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2
The Evolving Role of Hospital-Based Emergency Care
The emergence of the modern emergency department (ED) is a surprisingly recent development. Prior to the 1960s, emergency rooms were often poorly equipped, understaffed, unsupervised, and largely ignored. In many hospitals, the emergency room was a single room staffed by nurses and physicians with little or no training in the treatment of injuries. It was also common to use foreign medical school graduates in this capacity (Rosen, 1995). In teaching hospitals, the emergency areas were staffed by junior house officers, and faculty supervision was limited (Rosen, 1995). One young medical student in the 1950s described emergency rooms as “dismal places, staffed by doctors who could not keep a job—alcoholics and drifters” (University of Michigan, 2003, p. 50).
Over four decades, the hospital ED has been transformed into a highly effective setting for urgent and lifesaving care, as well as a core provider of ambulatory care in many communities. An extraordinary range of capabilities converge in the ED—highly trained emergency providers, the latest imaging and therapeutic technologies, and on-call specialists in almost every field—all available 24 hours a day, 7 days a week.
The appeal of the modern ED is undeniable—it is in some ways all things to all people. To the uninsured, it is a refuge. To the community physician, it is a valuable practice asset. To the patient, it is convenient, one-stop shopping. To the hospital itself, it is an escape valve for strained inpatient capacity. The demands being placed on emergency care, however, are overwhelming the system, and the result is a growing national crisis. The decrement in emergency care capacity and quality, however, is almost invisible to those outside the system. Few people have regular contact with

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the emergency care system, but when serious illness or injury strikes, the system they expect to be there may fail them, with catastrophic results. This chapter explains the increasing demands being placed on hospital-based emergency care, describes the nature of the crisis, and explores how it impacts individuals day to day.
IMBALANCE BETWEEN DEMAND AND CAPACITY
In the decade between 1993 and 2003, the United States experienced a net loss of 703 hospitals, an 11 percent decline. The number of inpatient beds fell by 198,000, or 17 percent, and the number of hospitals with EDs declined by 425, a 9 percent decrease (AHA, 2005b). This sharp decline in capacity was largely in response to cost-cutting measures and lower reimbursements by managed care, Medicare, and other payers (discussed below), as well as shorter lengths of stay and reduced admissions due to evolving clinical models of care.
During this same period, the population of the United States grew by 12 percent and hospital admissions by 13 percent. Between 1993 and 2003, ED visits rose from 90.3 to 113.9 million, a 26 percent increase, representing an average of more than 2 million additional visits per year (see Figure 2-1) (McCaig and Burt, 2005). The outcome of these intersecting trends of
FIGURE 2-1 Hospital EDs versus ED visits.
SOURCES: AHA, 2005b; McCaig and Burt, 2005.

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falling capacity and rising use was inevitable. By 2001, 60 percent of U.S. hospitals reported that they were operating at or over capacity (The Lewin Group, 2002).
Not only is ED volume increasing, but patients are presenting with more serious or complex illnesses. The U.S. population is aging, and thanks to advances in the treatment of HIV, cancer, and kidney and heart disease, many people live with significant comorbidities and chronic illnesses (Derlet and Richards, 2000; Bazzoli et al., 2003). These patients require more complex and time-consuming workups and treatments.
By law, the ED’s front door is always open, and there is growing public demand for its services. Among the normal flow of patients into the ED, some require hospitalization, some are treated and released, some are transferred, and a few die while in the ED. Nationwide, about 13.9 percent of ED patients were admitted to the hospital in 2003 (McCaig and Burt, 2005); this figure represents about 43 percent of all hospital patients in 2002 (Merrill and Elixhauser, 2005). But when a hospital’s inpatient beds are full, the result is a bottleneck to admitting the most severely ill and injured from the ED. As a result, patients who require hospitalization begin to back up in the ED (Andrulis et al., 1991; Asplin et al., 2003). The most common cause of this bottleneck is the inability to admit critically ill patients because all of the hospital’s intensive care unit (ICU) beds are filled (GAO, 2003). When delays in accessing inpatient beds become excessive, these patients are commonly referred to as “boarders” because they are technically inpatients but cannot leave the ED. “Boarder” is a misnomer, however, because it implies that these patients require little care. In fact, ED boarders often represent the sickest patients and the most complex cases in the ED—which is why they require hospitalization. And since these patients cannot be moved upstairs, the ED staff must provide ongoing care while simultaneously evaluating and stabilizing incoming ED patients. High levels of hospital occupancy not only create ED “boarders” but also can dramatically worsen ED crowding if community physicians who are unable to secure a bed for their scheduled admissions start sending patients through the ED instead. In either case, the normal congestion in the ED is increased. The problem is depicted in Figure 2-2.
The result of this imbalance is an epidemic of overcrowded EDs, frequent boarding of patients waiting for inpatient beds, diversion of ambulances, and patients who leave without being seen or leave against medical advice (Kellermann, 1991).
Overcrowding
ED overcrowding is a nationwide phenomenon, affecting urban and rural areas alike (Richardson et al., 2002). In one study, 91 percent of EDs

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FIGURE 2-2 Consequences of the imbalance between ED patient volume and inpatient capacity.
responding to a national survey reported overcrowding as a problem; almost 40 percent reported that overcrowding occurred daily (Derlet et al., 2001). Another study, using data from the National Emergency Department Overcrowding Study, found that academic medical center EDs were crowded on average 35 percent of the time. This study developed a common set of criteria for identifying crowding across hospitals based on several common elements: all ED beds full, people in hallways, diversion at some time, waiting room full, doctors rushed, and wait times to be treated of greater than 1 hour (Weiss et al., 2004; Bradley, 2005).
Overcrowding can adversely impact the quality of care in the ED and trauma centers. It can also lead to dangerous delays in treatment in the ED and cause delays in emergency medical services (EMS) transport (Schull et al., 2003, 2004).
Boarding
The most common cause of ED crowding is the boarding of admitted patients in the ED. A Government Accountability Office (GAO) study found that in 2001, 90 percent of hospitals boarded patients for at least 2 hours, and about 20 percent of hospitals reported an average boarding time of 8 hours (GAO, 2003). It is not unusual for patients in a busy hospital to board for up to 24 or even 48 hours. In a point-in-time survey of nearly 90 hospital EDs across the country, 73 percent of hospitals reported boarding two or more patients on a typical Monday evening (ACEP, 2003a). The potential for errors, life-threatening delays in treatment, and diminished overall quality of care is enormous in these situations (Andrulis et al., 1991; Conn, 1993; Litvak et al., 2001; Needleman et al., 2002; Schull et al., 2004).

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Ambulance Diversions
Another indication of the degree of ED crowding is the frequency of ambulances being diverted to alternative hospitals—a now common, if not daily, event in many major cities. According to the American Hospital Association (AHA), nearly half of all hospitals (46 percent), 68 percent of teaching hospitals, and 69 percent of urban hospitals reported time on diversion in 2004 (AHA, 2005b). A GAO study found that 69 percent of hospitals went on diversion at least once in 2001 (GAO, 2003). A Massachusetts Department of Public Health survey indicated that 67 of 76 hospitals responding to the survey “either diverted or employed special procedures” during one week in February 2001 to meet the demands on the ED (Massachusetts Department of Public Health, 2001). A report using data from the 2003 National Hospital Ambulatory Medical Care Survey indicated that 501,000 ambulances were diverted in 2003 (Burt et al., 2006).
To date, data on the health outcomes associated with diversion are limited. A 2002 study by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) revealed that over half of all ED events described as sentinel were caused by delayed treatment (Delays in Treatment, 2002). According to an AHA survey, hospitals reporting 20 percent or greater time spent on diversion had longer wait times for treatment by a physician, longer average lengths of stay in ED treatment, longer wait times for transfer from the ED to an acute or critical care bed, and longer wait times for transfer from the ED to a psychiatric bed (The Lewin Group, 2002). A study of trauma patients in Houston found that the numbers of deaths among these patients were consistently greater than average on days with high levels of diversion, but the differences were not statistically significant (Begley et al., 2004). In Canada, reports of a patient’s death while en route to an open hospital because his local ED was on diversion raised questions about the legality of ambulance diversion (Walker, 2002).
Ambulance diversions indicate a lack of ability to handle surges in the need for emergency care. If operating at a normal level forces ambulances to be diverted on a regular basis, it may be expected that in the event of a terrorist attack, natural disaster, or other severe and widespread medical emergency, the emergency system would be unprepared for the volume and severity of ED visits (Moroney, 2002).
Patients Who Leave Without Being Seen
In 2003, about 1.9 million ED patients left without being seen by a physician or other emergency care provider; this figure represents 1.7 percent of all ED patients, versus 1.1 percent in 1993 (McCaig and Burt, 2005). While the majority of these patients had low acuity levels, that was

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not always the case. Studies have shown that some of these patients were in need of immediate medical attention (Baker et al., 1991; Fernandes et al., 1997). One study revealed that those who left without being seen were twice as likely to report pain or a worsening of their problem as those who were seen. Another study found that 27 percent of those who left without being seen returned to an ED, and 4 percent required subsequent hospitalization (Bindman et al., 1991).
Crowding and wait times are important predictors of patients leaving the ED without being seen (Fernandes et al., 1994; Hobbs et al., 2000). One study found that the numbers of such patients increase as ED utilization rises above capacity (Quinn et al., 2003). In addition to patients who leave without being seen, another study found that about 1.2 million or 1 percent of all ED patients leave “against medical advice,” in other words, once assessment or treatment has begun, but before it has been completed (McCaig and Burt, 2005).
THE EMERGENCY DEPARTMENT AS A CORE COMPONENT OF COMMUNITY AMBULATORY CARE
The “Safety Net of the Safety Net”
Hospital EDs are the provider of last resort for millions of patients who are uninsured or lack adequate access to care from community providers. The number of uninsured in the United States is now estimated to exceed 45 million and continues to climb (DeNavas-Walt et al., 2005); the number is expected to reach 51.2–53.7 million by 2006 (Simmons and Goldberg, 2003). Some suggest that an additional 29 million Americans are underinsured, lacking sufficient coverage for essential medical care (O’Brien et al., 1999).
The Institute of Medicine (IOM) report America’s Health Care Safety Net: Intact but Endangered called attention to the growing threats to the nation’s health care safety net—increasing numbers of uninsured; erosion of direct and indirect subsidies to providers, including Medicaid Disproportionate Share Hospital (DSH) payments and cost-based reimbursement to Federally Qualified Health Centers (FQHCs); and the continuing growth of Medicaid managed care, which lowers payments and diverts patients from core safety net providers (IOM, 2000). The IOM’s six-part Insuring Health series comprehensively examined the consequences of uninsurance in the United States. A Shared Destiny: Community Effects of Uninsurance, one of the reports in that series, demonstrated the impact of uninsurance on the demand for safety net services and in particular the burden this places on an overextended emergency care system (IOM, 2003). Many of

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these uninsured patients have no regular source of care and fail to realize the benefits associated with having a primary care provider. An earlier IOM Report, Primary Care: America’s Health in a New Era, examined the features of primary care—including integration of medical services; coordination of physical, mental, emotional, and social concerns; and sustained clinician–patient relationships—and documented the decrements in quality of care and health that result from inadequate public access to primary care (IOM, 1996). With limited access to community-based alternatives to the emergency system—public clinics, specialists, psychiatric facilities, and other services—many of these people turn to the emergency care system when in medical need, often for conditions that have worsened because of a lack of primary care.
Because the emergency care system is the only component of the nation’s safety net that must provide care to everyone, regardless of insurance coverage or ability to pay, hospitals have no alternative but to try to absorb these patients as best as they can. Community-based services, when faced with high demand, can restrict access. Community health centers typically operate only during business hours, maintain long waiting lists, and may lack significant specialty and diagnostic services that are required to fully address their patients’ needs. EDs, by contrast, have no such options—they are mandated to serve all who come. Without the ED to fall back on, other community safety net services would be equally overwhelmed. Thus, the emergency care system truly has become the “safety net of the safety net.”
Use of the ED for Nonurgent Care
Just over half of ED visits in 2003 were categorized as emergent or urgent, translating into a need for care within 15 minutes to 1 hour of arrival at the ED, while about 33 percent of visits were categorized as semiurgent or nonurgent, requiring attention within 1 hour or 24 hours, respectively (McCaig and Burt, 2004) (see Figure 2-3). Defining ED care as nonurgent or medically unnecessary is controversial because the terms are difficult to define and may vary depending on who is defining them. Is necessity determined by the patient’s signs and symptoms at the time of arrival, or by the diagnosis at the time of hospital admission or discharge from the ED? A patient with chest pain would certainly consider this a proper reason to seek ED care, but a patient discharged with a diagnosis of heartburn might be judged by his insurer to have made an inappropriate ED visit. How likely is it that a physician, patient, and insurer will agree on the level of urgency of any given case? Around these gray areas, however, most would agree that there are patients who could be treated as well or better in a different setting if this care were available.

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FIGURE 2-3 Percent distribution of ED visits by the immediacy with which patients should be seen, 2003.
SOURCE: McCaig and Burt, 2005.
Other components of the health care system that serve large safety net populations have received substantial government support. For example, community health centers are funded by a federal grant program under Section 330 of the Public Health Service Act and are administered by the Health Resources and Services Administration (HRSA). They received more than $1.7 billion in federal funding in 2005 and served an estimated 14 million patients. In fiscal year 2002, President Bush proposed a 5-year, $780 million initiative to increase the number of community health center sites throughout the nation in order to reach an additional 6.1 million patients by the end of 2006. By the end of 2005, 428 new sites had been established, and many more had increased their medical capacity (HRSA Bureau of Primary Health Care, 2006).
A recent report of the Centers for Disease Control and Prevention (CDC) revealed that EDs represent an important component of the ambulatory care system (12.7 percent of all visits) (Schappert and Burt, 2006). The proportion is much higher in many rural and urban communities where the local ED is the principal provider. Despite its importance in providing ambulatory care and the legal requirement to accept all patients regardless of insurance coverage or ability to pay, hospital emergency care receives little direct federal support.

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Why Nonurgent Patients Use the ED
Research has identified several important determinants of nonurgent utilization of the ED. These include financial barriers to and limited availability of alternative sources of care, referrals to the ED by community physicians, and patients’ preference for the ED over other alternatives.
Financial barriers Studies have shown that a significant number of patients use the ED for nonurgent matters because of financial barriers. While often unable to access private physician practices, uninsured patients do have access to public health clinics operated by local and county health departments, including FQHCs. But these clinics are limited in number and geographic distribution. In addition, they may have limited hours, long waits, and queues for new patients. Unlike EDs, they are neither typically open around the clock nor required by law to accept all who come. They may also have limited services. For example, many provide primary care services but lack the resources to provide specialty care and diagnostic services. Results of a recent study suggest that expanding primary care capacity may actually increase demand for ED care (Cunningham and May, 2003). According to the authors, patients with access to primary care are more likely to seek specialty care and diagnostic services.
Although Medicaid beneficiaries have a source of payment for medical care, the rates of reimbursement are so low that the number of office-based practitioners who are willing to accept such patients is low (The Medicaid Access Study Group, 1994). One study (Oster and Bindman, 2003) found that uninsured and Medicaid patients have higher rates of ED utilization and are less likely to have a follow-up visit scheduled with a regular physician. In another study, research assistants posing as Medicaid patients attempted to secure appointments with clinics and physician practices. Fully 56 percent of these providers declined to give an appointment, and the most prevalent reason given was “not accepting Medicaid patients.” When asked for an alternative, most either offered none or advised the caller to “go to an emergency room” (The Medicaid Access Study Group, 1994). Similar barriers to follow-up care exist as well, even after an ED visit for a serious health problem (Asplin et al., 2005). Research assistants posing as ED patients telephoned physician offices and clinics to schedule an urgent follow-up visit for a serious problem diagnosed in the ED (pneumonia, severe hypertension, or suspected ectopic pregnancy). When callers stated that they had private insurance coverage, they were almost twice as likely to get an appointment as the same callers when they stated that they were covered by Medicaid, and about 2.5 times more likely to get an appointment than when they stated a willingness to pay $20 up front and arrange for complete payment later. Of note, nearly 98 percent of clinics specifically

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inquired about the caller’s ability to pay, but only 28 percent inquired about the caller’s health.
One consequence of Medicaid patients’ lack of access to primary care is greater reliance on the ED. Medicaid recipients use the ED more than any other group, and their rate of utilization is increasing—81 visits per 100 persons in 2003, versus 65.4 per 100 the year before. This is double the rate of the uninsured population (41.4 percent) and nearly four times that of privately insured patients (21.5 percent) (McCaig and Burt, 2005). All but privately insured individuals also increased their utilization rates from the year before (McCaig and Burt, 2004, 2005). Numerous studies have also found that Medicaid patients disproportionately use the ED for nonurgent conditions, often relying on the ED as their primary source of care (Cunningham et al., 1995; Liu et al., 1999; Sarver et al., 2002; Irvin et al., 2003b). This phenomenon appears to be due largely to a lack of access to care in other settings.
Limited availability of alternative sources of care Even in the absence of financial barriers, patients may use the ED because of limited access to alternative sources of care. Having a usual source of care can deter utilization of the ED for nonurgent purposes (Petersen et al., 1998), but even patients with a usual source of care frequently use the ED after hours when clinics and physician offices are closed. Recent trends in utilization indicate that insured patients, who are less likely to face financial barriers, are using the ED in larger numbers (Cunningham and May, 2003). The most common reason “walk-in” patients seek care in the ED is because they are experiencing painful or worrisome symptoms that they believe require immediate evaluation and treatment (Young et al., 1996).
The ED as an adjunct to physician practices There is evidence that physicians and clinics are increasingly using the ED as an adjunct to their practices, referring patients there for a variety of reasons, including their own convenience after regular hours, reluctance to take on complicated cases, the need for diagnostic tests that they cannot perform in the office, and liability concerns (Berenson et al., 2003; Studdert et al., 2005). In a three-site study in Phoenix, Arizona, researchers found that while two-thirds of patients had not contacted a health professional prior to their ED visit, 80 percent of those who had done so had been referred to the ED (St. Luke’s Health Initiative, 2004). The Medicaid Access Study Group found that a majority of clinics that declined to see Medicaid patients with minor problems failed to offer any advice about alternatives. The second most common option was to tell the caller to seek care in an ED. A national study of ambulatory use of hospital EDs revealed that 19 percent of “walk-in” patients had been instructed to seek care in the ED by a health care provider (Young et al.,

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1996). This phenomenon, sometimes called “physician deflection,” is likely to accelerate in the future because primary care offices will be unable to keep pace with the technological advances required to address complex patient needs. Office physicians may consider potentially acute patients to be safer in the ED, and therefore refer such patients directly to the ED even if appointments are available. In addition, referral to the ED has sometimes become the only way to refer patients to certain specialists, who refuse Medicaid patients in many cases. Chronic disease management, medication management, counseling, and case management resources, on the other hand, are aspects of care that primary and specialty care ambulatory practices should be able to provide as an alternative to the ED.
Patient preference Patients are increasingly using the ED for the convenience of obtaining timely resolution of health care problems (Young et al., 1996; Guttman et al., 2003). Some patients use the ED if they feel they need immediate attention but cannot see their primary care provider within 24 hours (Stratmann and Ullman, 1975; Andren and Rosenqvist, 1985). Patients who try to reach their physician by phone in the evening or on weekends may have difficulty getting through or may be instructed to use the ED. Patients whose primary care providers have extended evening or weekend office hours have been found to have lower rates of ED utilization (Lowe et al., 2003).
Patients may also prefer the ED if they believe it is the best place to obtain access to specialized equipment (Roth, 1971; Smith and McNamara, 1988; Brown and Goel, 1994). Increasingly, admitting physicians are insisting that EDs complete highly detailed workups before they will admit a patient to the hospital. This may explain in part the increasing use of diagnostics such as magnetic resonance imaging (MRI) and computer-assisted tomography (CAT) scans in the ED—up 103 percent from 1992–1999 according to CDC. Some patients may also view the ED as a convenient site for one-stop shopping for medical care. Even with a wait of 2 or more hours, patients can have all of their needs met in a single visit to the ED, and possibly avoid a much longer total time spent seeking care and obtaining diagnostic testing from multiple providers.
Concerns About Nonurgent Utilization
The delivery of nonurgent care in the ED is of concern for three reasons. First, the primary care delivered in the ED may be of lower quality than that in other settings. The ED is designed for rapid, high-intensity response to acute injuries and illnesses. It is fast-paced and requires intensive concentration of resources for short durations. Such an environment is ill suited to the provision of primary and preventive care (Derlet and Richards, 2000).

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with respect to decisions about local versus regional delivery sites. Current approaches to these training needs include encouraging joint training programs with rural hospitals and funding rural training programs.
Quality of Care
Disparities in the quality of care between rural and nonrural areas and the resulting potential for adverse events and suboptimal outcomes have repeatedly been demonstrated (Bachman et al., 1986; Vukov et al., 1988; Eitel et al., 1988; Olson et al., 1989; Gallehr and Vukov, 1993; Richless et al., 1993). Low population density has been strongly associated with increased trauma-related death rates (Rutledge et al., 1994), and preventable death rates in rural areas have been demonstrated to be twice those in urban areas (Esposito et al., 1995). In some studies, death rates from trauma among rural children have been reported to be nearly double those among urban children (Svenson et al., 1996). Likewise, geriatric trauma patients in rural areas have higher complication rates and in-hospital mortality (Rogers et al., 2001). Killien and colleagues (1996) pointed out that with respect to out-of-hospital cardiac arrest, rates of survival to discharge were reported to be as high as 32 percent in urban studies, compared with less than 10 percent in most rural studies.
SUMMARY OF RECOMMENDATIONS
2.1: Congress should establish dedicated funding, separate from Disproportionate Share Hospital payments, to reimburse hospitals that provide significant amounts of uncompensated emergency and trauma care for the financial losses incurred by providing those services.
2.1a: Congress should initially appropriate $50 million for the purpose, to be administered by the Centers for Medicare and Medicaid Services.
2.1b: The Centers for Medicare and Medicaid Services should establish a working group to determine the allocation of these funds, which should be targeted to providers and localities at greatest risk; the working group should then determine funding needs for subsequent years.